Eyeworld Supplements

4 EW Chicago 2012 Monday, April 23, 2012 4 use of the EX-PRESS device com- pared to standard filtration surgery. Additionally, as I reported in a recent publication, EX-PRESS device patients have fewer post-op visits during initial follow-up and have a quicker return to baseline visual acuity compared to those patients undergoing trabeculectomy in my hands. 1 The EX-PRESS Glaucoma Filtration Device is intended to reduce intraocular pressure in glaucoma patients where medical and conventional surgical treat- ments have failed. My experience with selecting patients for the EX-PRESS Glaucoma Filtration Device Patients who undergo phacoemulsi- fication and filtration at the same time may also be candidates for the EX-PRESS device. Twenty percent of cataract surgeries are performed on patients who also have glaucoma. When combined cataract and glaucoma surgery is planned, use of the EX-PRESS device can be consid- ered as an option. In those patients deemed at high risk for hypotony, the EX-PRESS device may be considered as an alternative to trabeculectomy due to the flow regulation that the device provides. If there is a need for quicker visual recovery, as is the case with the monocular patient, the EX-PRESS device provides a visual recovery that is possibly faster than traditional trabeculectomy. 1 The reduced time of recovery to baseline visual acuity is crucial and justifies the added cost of surgery incurred with use of the EX-PRESS device. Another population where the EX-PRESS device would be favored over trabeculectomy, due to the lower risk of bleeding with the EX-PRESS device, is those patients who are anticoagulated. In patients with a history of inflammatory problems, the EX-PRESS device might offer an advantage due to the decrease in tissue manipulation. Surgical pearls A filtration procedure employing the EX-PRESS device right up to the implantation of the device is very similar to trabeculectomy. A conjunctival peritomy and scleral flap are created in similar fashions, for example. However, instead of performing an incision and tissue punch thereafter, a sclerostomy with a 25- to 27-gauge needle is performed to implant the device. The conclusion of surgery also comes more in line with trabeculec- tomy, as suturing down the scleral flap and conjunctiva occurs in both procedures and in a similar fashion. When implanting the EX-PRESS device, ensure the scleral flap is large enough to cover the faceplate of the device (3 mm by 3 mm is required). At the entry site, a pilot hole is created with a 25- to 27-gauge needle; positioning and ensuring the plane is parallel to the iris is impor- tant. When placing the EX-PRESS device through the pilot hole, the faceplate needs to be flat on the sclera. There is a learning curve with proper EX-PRESS device placement. Those surgeons who perform trabeculectomy routinely should be able to learn the skills for EX-PRESS device implantation relatively fast. A multicenter, randomized study examining a standard trabeculectomy with mitomycin-C (MMC) compared to the EX-PRESS device with MMC is needed. Fortu- nately, there is a recently completed study that is currently being ana- lyzed that may shed some light on both procedures in light of the mul- ticenter nature of the study. How these procedures will fare with multiple surgeons involved, multiple skill sets, and different backgrounds will be enlightening. Now is the golden age of glau- coma procedures—from minimally invasive procedures to therapy more tailored to a particular glaucoma pa- tient's needs. While trabeculectomy remains the gold standard, other devices are gaining ground in providing more predictable results in select cases. The EX-PRESS device is a large part of this new and effective device community and will likely continue to be so for some time. Reference 1. Good, TJ, Kahook, MY. Assessment of Bleb Morphologic Features and Postoperative Outcomes after EX-PRESS Drainage Device Implantation versus Trabeculectomy. American Journal of Ophthalmology. 2011. 151:507- 514. Dr. Kahook is associate professor of ophthal- mology and bioengineering, director of clinical and translational research, and director of the Glaucoma Service and fellowship, University of Colorado Hospital Eye Center. Contact information Kahook: malik.kahook@gmail.com Kahook continued from page 3 The EX-PRESS device compared to the size of a penny Source: Alcon Please refer to pages 10-12 for important safety information about the Alcon surgical products described in this supplement. EX-PRESS delivery device Source: Alcon

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